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Frequently asked questions about radioactive seed treatment in prostate cancer
Introduction:
The collection of questions and answers shown here is are courtesy of Prof. Haim Matzkin, Chief Department of Urology at the Ichilov Hospital - Tel Aviv Medical Center, and medical director of the Proscare Center for Iodine and Palladium radioactive seed treatment of prostate cancer -Brachytherapy. The questions and answers are based on the personal experience of Prof. Matzkin in Brachytherapy treatment and at the time these lines where written over nine hundred of such treatments where conducted. Two world-leading companies in this area of treatment in prostate cancer have elected Prof. Matzkin to be their tutor in European countries as to the use of this technique.

1. What basic data does a prostate cancer patient need in order to be a reasonable candidate for radioactive seed implantation treatment?
Most men can be candidates of the treatment. Since the surgical procedure is minor it is possible to perform it in men suffering from other diseases like diabetes, high blood pressure etc.
The procedure can be conducted at any age, despite the fact that elderly men, over 80 years old, should discuss with their doctors if the disease needs treatment at all. In very rare cases elderly men with a very large prostate or after having surgery done for a benign enlarged prostate can't undergo the treatment, or have technical problems that prevent optimal treatment.

Men with PSA blood level of less than 20 ng/mL and a prostate biopsy result up to Gleason score 6 are candidates for Brachytherapy with radioactive iodine seeds only. Men with a Gleason score of 7 have higher have a higher prospect of the disease spread out of the prostate boundaries, and a combined treatment of radioactive iodine seed (I-125) or Palladium (Pd-103) and a short, one month long, course of external radiation is justified.
The challenge withstanding the caring urologist is to match the right treatment for a certain patient.

2. Why do some of the patients receive external radiation? Isn't it always better to add it?
The treatment with radioactive iodine seeds, much like the radical surgery of the prostate, is based upon the assumption that the cancer is only in the prostate -localized. With low PSA levels in the blood, a finger examination of the prostate that supports a small localized disease,- that is indeed the condition of most patients. For those patients single Brachytherapy treatment , using iodine radioactive seeds, in an ambulatory, non-hospitalized way , is sufficient enough. Experience with treating thousands of patients justifies this "minimal" treatment approach. Despite that, certain patients (no more than 25% of all now-a-days diagnosed patients) do have a higher chance of disease spreading beyond the boundaries of the prostate and therefore "enjoy" an additional radioactive treatment that lasts 4 weeks.

3. What basic tests must patients forgo before the treatment?
The basic tests can be divided to three categories - First - tests required before deciding that treatment is indeed necessary - for that one needs current blood test for PSA, a biopsy of the prostate (in border-line cases the same biopsy is needed for a re-evaluation (review) by the medical staff that includes an experienced pathologist). Sometimes a bone scan is required, and rarely a CT of the pelvis and prostate.
Second - this set of tests will already be conducted at the Proscare Center after the patient had already decided on the Brachytherapy treatment option and after urological examination and a some background medical information is obtained. The basic test is an ultrasound examination of the prostate, similar but not identical to the one done during the prostate biopsy you already had. This test is conducted to obtain a 3-dimensional exact image of the prostate. This image along with volume calculations, will serve us, and mainly the radiation physicist, in ordering the radioactive seeds and planning the specific radioactivity for your case. Every patient has an individual order that depends on prostate size, volume and which treatment was elected - whether it's Brachytherapy alone or a combined treatment with external radiation.
The ultrasound test will be conducted about a month before the designated treatment. Third group of tests conducted near the designated date of treatment and includes general blood tests such as - sugar levels, blood count etc., urine culture, chest x-rays and electrocardiogram (a rhythm chart of the heart). All those are conducted in order to make sure your general health is fine and ready for the examination of an expert anesthetist, since the Brachytherapy is conducted under general or local anesthesia (epidermal).

4. On what grounds is the type of radioactive seed, iodine or palladium, chosen?
As mentioned before, the main factor in this decision is Gleason score in the biopsy you had. The Gleason score describes the kind of cells discovered in your prostate cancer. When it's 2-6 - we will use iodine (I-125). When it is 7, one can use both elements; the results won't change despite the fact an exact comparison was never made. When Gleason score is 8, most experts, me included, will prefer palladium. This seems the place to remind and emphasize that in Gleason scores 7-8, it is customary to combine the treatment with an additional external radiation, as if to sterilize the surrounding of the prostate should there be a microscopic spread outside the gland.
The difference between the two sources is the rate in which radiation is discharged-delivered . In palladium it is faster. For instance, iodine discharges half its radiation in 60 days, palladium in 17 days. After two months in which the iodine discharged half its radiation, the palladium discharged about 90% of his. As a result, the calculation of the total radiation amounts is different between these two elements, a fact taken into consideration by the physicist and the computerized system adjusting your treatment. More to be said, palladium is much more expensive then iodine.

5. Please describe the treatment itself, its length, and how I should prepare myself to it?
The treatment is conducted in an operating room along with specifically destined equipment purchased for it and includes an ultrasound system, a stereo-tactical system (for exact localization of the needles and seeds), and advanced computerization..
The procedure takes approx. an hour. It is conducted under anesthesia. It is possible to do it under general anesthesia or epidural or spinal one. Choosing between those two options makes no difference to us, and will be discussed with you and decided by the anesthetist, that will explain his preferences and approach to the matter.
You will arrive at Proscare Center located at the Ramat Aviv Medical Center in Tel Aviv several hours before the designated time of treatment , where you will be seen by the anesthetist and prepared for the operating room. You must fast 12 hours before the treatment and do, by yourself, an enema as will be explained by the nurse in one of the pre-treatment sessions.
After the procedure you will remain a few hours in recovery or in your own room. Recovery time is obviously individual; therefore you may be released 3-4 hours after the treatment or observed a few more hours before being released.
Your discharge is conditioned by a spontaneous urination.
Due to the fact that a swelling is predicted in the area under the scrotum (as a result of the seed penetration), an icepack will be placed at the end of the treatment, in the perineum and kept for a few hours.
You are allowed to receive pain medication.
Aspirin and other blood thinning drugs aren't allowed for at least 10 day before and 14 days after the treatment.
After the anesthesia had worn off there is no prevention for you to have a normal meal or get back to normal activities - walking, working etc.

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